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Biomedical subjects

R Gokal

Publications and source records attributed to R Gokal.

At least 19 recordsLinked to original sources
PubMed1999

Haemodialysis.

This paper charts the development of haemodialysis, the cornerstone of renal replacement therapy (RRT). It has enabled patients with end-stage renal failure to survive for years, in many cases with a surprisingly good quality of life. Through technological advances, RRT can be offered to patients who are older and more frail. Many have intercurrent comorbid illness. Such patients can have good quality of life, but their survival is shorter since they are likely to succumb early to comorbid illnesses. The challenge to nephrologists is to provide treatment based on exacting standards for all those patients who can benefit, yet to maintain cost-effectiveness. There is increasing recognition that, however good the technology underpinning dialysis, what justifies the cost and commitment that dialysis entails is the provision for the patient of a satisfactory quality of life.

Adult↗
PubMed1999

Morbidity and mortality in redefining adequacy of peritoneal dialysis: a step beyond the National Kidney Foundation Dialysis Outcomes Quality Initiative.

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) Peritoneal Dialysis (PD) Adequacy Work Group intentionally limited the scope of its work to address adequacy in terms of small-solute removal. This decision was based on the need for rigorous evidence and that mortality is the most objective parameter in the literature. This review attempts to more broadly redefine the concept of the adequacy of PD, particularly as it relates to the most common general medical problems that PD patients experience; namely, cardiovascular disease and malnutrition. Whereas we are sensitive to the developmental process of the NKF-DOQI, we are critical that the definition of adequacy may be too narrow, leading clinicians to overlook other important morbidities. We have reiterated the evidence that suggests a weekly solute clearance (Kt/Vurea) of 1.7 or greater is associated with better patient survival. The arguments to target a greater Kt/Vurea of 2.0 are challenged, yet the concept is ultimately supported. Because cardiovascular disease is the cause of death in half of all patients with end-stage renal disease, dialysis adequacy must be defined, in part, by the potential of that therapy to diminish cardiovascular maladies. Blood pressure, volume, left ventricular hypertrophy, and dyslipidemias are discussed in this context. Lastly, assumptions that increasing total solute clearance leads to improved nutrition in PD patients are challenged. We have attempted to expand on what the NKF-DOQI did not include, and we urge the dialysis community to seek the answers to the many controversies that remain. We need to redefine the adequacy of PD in a holistic manner and find outcome parameters that are not as final as death.

Cardiovascular Diseases↗
PubMed1999

Bone loss in long-term renal transplantation: histopathology and densitometry analysis.

BACKGROUND: There is little information of the spectrum and factors implicated in the bone loss in long-term renal transplantation, and virtually no data using both histomorphometric and densitometric analysis. METHODS: Twenty-three males and 22 females (13 postmenopausal) were studied with a bone biopsy and densitometry. Sixteen patients were on cyclosporine A monotherapy, 20 on azathioprine + prednisolone, and 9 on cyclosporine A + prednisolone or triple therapy. The mean time after transplantation was 127 +/- 70 months. RESULTS: No group had a significant decrease in bone mineral density (BMD) of the axial skeleton compared with an age- and sex-matched normal population. Compared with sex-matched young controls, osteopenia was observed in all groups at the femoral neck (except premenopausal women and triple therapy) and in the triple-therapy group at the L1-L4 spine region. At the distal radius, osteopenia was found in all the groups. Histopathological diagnosis was mixed uremic osteodystrophy in 46.5%, adynamic bone in 23.2%, hyperparathyroid disease in 13.9%, and normal bone in 16.3%. The diagnosis was not different according to immunosuppressive therapy, but men tended to show more mixed uremic bone disease. There was no significant difference in BMD between histopathological subtypes. In general, patients showed slight osteoclast function increase, osteoblast function decrease, and marked retardation of dynamic parameters. The cyclosporine A monotherapy group had a significantly lower appositional rate than azathioprine + prednisolone. Men had a significantly lower bone volume than women, and premenopausal women had a significantly lower mineralizing surface than postmenopausal women and men. In the multivariate analysis, male gender, time after transplantation, old age, and time on dialysis prior to transplantation were significant predictive factors for a negative effect on bone mass. CONCLUSIONS: Long-term renal transplant-patients showed reduced BMD in both trabecular and cortical bone. This reduction in BMD was not as severe as in short-term reports and was associated with osteoclast stimulation, osteoblast suppression, and retardation of mineral apposition and bone formation rates. Bone mass loss was not different between the immunosuppression therapy groups. Male gender and age were the strongest predictive factors for low bone mass.

Absorptiometry, Photon↗
PubMed1999

Neuropathy and quality of life in diabetic continuous ambulatory peritoneal dialysis patients.

Diabetes mellitus is the commonest cause of end-stage renal failure and is associated with considerable morbidity. Neuropathy is one of the most serious complications of diabetes, linked to the incidence of nephropathy and retinopathy. The prevalence of neuropathy increases with age and duration of diabetes. Peripheral sensorimotor neuropathy is the main manifestation of neurological damage in diabetes, while autonomic neuropathy, a devastating complication, is also present in a large number of patients with long-term diabetes. Clinical features of autonomic neuropathy are mainly cardiovascular disorders and abnormal visceral function. One of the most important sequelae of neuropathy is the development of the insensitive foot at risk of ulceration, deformation, Charcot neuroarthropathy, and amputation. Prevention, education, and identification of the at-risk patient are the key elements in managing these severe complications. Dialysis, and mainly peritoneal dialysis, still remains the main renal replacement therapy for end-stage renal disease (ESRD) diabetic patients. It is obvious from many studies that diabetes and its complications are major risk factors associated with poorer survival rates, increased morbidity, and decreased quality of life. Few, if any, data are available specifically evaluating quality of life in continuous ambulatory peritoneal dialysis (CAPD) diabetic patients. Fewer data are available estimating the impact of neuropathy on the quality of life of such patients. Specific studies must be carried out to further investigate quality-of-life issues and neuropathy in this vulnerable group of patients.

Autonomic Nervous System Diseases↗
PubMed1998

Does peripheral neuropathy invariably accompany nephropathy in type 1 diabetes mellitus?

In patients with Type 1 diabetes mellitus complicated by diabetic nephropathy and retinopathy, it is usually believed that significant neuropathy is almost universal, but few studies have directly addressed this. This study assessed neuropathy in 91 such subjects, using vibration perception thresholds (VPT) and the neuropathy disability score (NDS). A total of 34% of subjects had no neuropathy on age adjusted VPT (z score) and 26% had no neuropathy on NDS. The severity of neuropathy as measured by VPT z score was related to increasing glycated haemoglobin (P = 0.02) and male sex (P = 0.03), and NDS was independently associated with age (P < 0.0001) and HbA1c (P = 0.003). These factors together accounted for only 12 and 31% of the total variance in VPT z score and NDS, respectively. In conclusion, the study has shown that a significant proportion of patients with diabetic nephropathy are free of neuropathy, but the full explanation for their protection from neuropathy is unclear.

Adult↗
PubMed1998

Icodextrin provides long dwell peritoneal dialysis and maintenance of intraperitoneal volume.

Icodextrin 7.5% is an isosmolar solution for once-daily use in peritoneal dialysis for patients with end-stage renal failure (ESRF). It produces substantial ultrafiltration (UF), performing best over longer dwells of 8-12 h in continuous ambulatory peritoneal dialysis (CAPD) patients, and up to 16 h in automated peritoneal dialysis (APD) patients. Subsequent use in other clinical areas (ultrafiltration failure) and normal postmarketing clinical experience has established its tolerability and safety profiles; a small number of patients, including those with diabetes, have now received icodextrin for up to 6 years. Icodextrin's ability to maintain intraperitoneal volume over many hours has led to its undergoing development as an intraperitoneal drug delivery system for targeted regional delivery of anticancer drugs and lymphatic delivery of anti-HIV treatment. Isosmolar icodextrin 7.5% solution represents the first major advance in the treatment of ESRF by peritoneal dialysis since the development of CAPD using glucose-based solutions 20 years ago.

Dialysis Solutions↗
PubMed1998

A controlled trial of two bicarbonate-containing dialysis fluids for CAPD--final report.

BACKGROUND: The combination of a low pH and a high concentration of lactate which is present in most dialysis fluids is found to be cytotoxic in vitro. For these reasons it would seem logical to use a bicarbonate-containing solution and thus automatically provide a solution with a neutral pH. METHODS: A parallel, randomized, open-label, prospective 2-month trial with an optional 4 month extension was undertaken to compare two novel bicarbonate-based solutions; one containing 38 mmol/l of bicarbonate (B), and one containing a mixture of 25 mmol/l bicarbonate and 15 mmol/l of lactate (B/L), with a control solution (C) containing 40 mmol/l lactate. RESULTS: Three groups of 19 (C), 20 (B), and 20 (B/L) patients were recruited and data from approximately 55 patient months were accumulated in each group. The data show that both bicarbonate-based solutions maintain acid-base levels within the normal range, that there were no changes in any of the other blood biochemistry parameters measured in the peritoneal equilibration test or with regard to adequacy of dialysis, and that furthermore, both solutions were well tolerated. CONCLUSIONS: This study showed that either the bicarbonate or bicarbonate/lactate solutions could be utilized efficaciously in patients undergoing CAPD.

Acid-Base Equilibrium↗
PubMed1998

Bicarbonate and bicarbonate/lactate peritoneal dialysis solutions for the treatment of infusion pain.

A randomized, double-blind, cross-over study was undertaken to determine the effects of novel bicarbonate (38 mM) and bicarbonate (25 mM)/lactate (15 mM) containing peritoneal dialysis (PD) solutions on infusion pain in patients who experienced inflow pain with conventional lactate (40 mM) solution. Pain was assessed using a verbal rating scale and the validated McGill Pain Questionnaire (MPQ). Eighteen patients were recruited to the study. Both novel solutions resulted in highly statistically significant reductions in inflow pain compared to the control lactate solution, as assessed with both the verbal rating scale and the MPQ. For all pain variables assessed, the bicarbonate/lactate solution was more effective than the bicarbonate solution in alleviating pain. In conclusion, both solutions reduced the infusion pain experienced with control solution, but the bicarbonate/lactate solution appears to be the most effective. In contrast to the most widespread current treatment, which is the manual injection of sodium bicarbonate, the bicarbonate/lactate solution does not have the associated increased risk of peritonitis.

Bicarbonates↗
PubMed1997

Impact of increasing dialysis volume on adequacy targets: a prospective study.

Failure to achieve target values for both urea (Kt/V) and creatinine clearance has been associated with increased morbidity and mortality in continuous ambulatory peritoneal dialysis patients. The conventional continuous ambulatory peritoneal dialysis regimen, which uses four 2-L exchanges per day, has resulted in up to 40% of such patients failing to achieve proposed targets for weekly Kt/V of 1.7 and weekly creatinine clearance (WCC) of 50 L. In a prospective study, the impact of increasing prescribed volumes by 0.5 L per exchange was evaluated on attaining urea and creatinine clearance targets over a 1-yr period. At 1 yr, 17 patients remaining on the increased dialysis prescription were compared with 18 patients remaining on an unchanged regimen. The mean increase in daily prescribed volume was 1.5 L (22%). This resulted in a significant increase in both peritoneal dialysis Kt/V (1.59 to 1.78 L = 12%) and peritoneal dialysis WCC (45.8 to 50.1 L = 10%) by 1 yr. Because of loss of renal function, there was no significant increase in total clearance at 1 yr, but this loss of renal clearance was offset by the gain in peritoneal clearance. Residual renal function fell at a similar rate in both the increased dialysis and control groups. In the latter, although peritoneal clearance remained stable over the 1-yr period, loss of renal function resulted in reductions in both total Kt/V and WCC. In conclusion, exchange volume can be increased to compensate for loss of renal function over a 1-yr period. Progressive loss of renal clearance resulted in only a modest gain in total solute clearance. It was the larger patients who tolerated the increase in exchange volumes. However, such patients (by virtue of their size) tended not to achieve target values for solute clearance, and the modest gain in peritoneal clearance was insufficient to increase the number of patients in this group achieving such targets for dialysis adequacy.

Adult↗